Payment Integrity Investigator

We are recruiting for a motivated Payment Integrity Investigator to join our team! We are here for lifes journey. Where is your life journey taking you? Being the heartbeat of Denver means our heart reflects something bigger than ourselves, something that connects us all: Humanity in action, Triumph in hardship, Transformation in health. Department Managed Care Administration Job Summary Under minimal supervision this position is responsible for detecting and investigating alleged or suspected fraud, waste, and/or abuse (FWA) by providers or enrolled members. As an investigator, you will conduct various activities to support Denver Health Medical Plan's (DHMP) FWA prevention and detection program. Essential Functions: Conduct proactive FWA detection and monitoring via various techniques and tools including, but not limited to, data mining and analytics. (10%) Collaborate with DHMP departments and leadership to investigate allegations of FWA. (10%) Perform analysis of applicable regulations, contracts, and policy manuals to determine whether violations exist. (10%) Collect, analyze, and document evidence related to FWA investigations and/or projects to include, but not limited to: (10%) Conducting and documenting interviews of witnesses or subjects. (10%) Perform field work to include provider site visits and surveillance. (10%) Compile and organize accurate case file documentation and calculation of potential overpayments. (5%) Make referrals of case findings to appropriate law enforcement and/or regulators. Develop investigative summary reports documenting investigative activities and findings. (5%) Suggest program integrity measures and controls to enhance FWA prevention work. (5%) Serve as a resource for departments to research and resolve integrity inquiries and assist in identification of improvements to internal practices that may reduce or prevent FWA. (5%) Represent DHMP as a witness in court actions as required, and in affidavits as assigned. (5%) Support other team members within the Corporate Compliance Department, as assigned. (5%) Participate in preparing and submitting required reporting to regulatory agencies. (5%) Respond to data requests submitted by external authorized parties. (5%) Education: Bachelor's Degree Required or High School Diploma or GED Required and Demonstrated experience. Required Work Experience: 1-3 years At least two years of experience performing investigations or audits in the health care arena. Required Licenses: CPC - Certified Professional Coder - AAPC - American Academy of Professional Coders Required Knowledge, Skills and Abilities: Knowledge of medical terminology, healthcare claims, and medical coding. Demonstrated experience using data to perform investigations or audits, including intermediate skill level with Excel. Knowledge of Medicare and Medicaid requirements. Proficiency in Microsoft Office. Shift Work Type Regular Salary $58,700.00 - $88,100.00 / yr Benefits Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans Free RTD EcoPass (public transportation) On-site employee fitness center and wellness classes Childcare discount programs & exclusive perks on large brands, travel, and more Tuition reimbursement & assistance Education & development opportunities including career pathways and coaching Professional clinical advancement program & shared governance Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer Our Values Respect Belonging Accountability Transparency All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denvers 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, a Public Health Institute, an HMO and The Denver Health Foundation. As Colorados primary, and essential, safety-net institution, Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community, focusing on hiring and purchasing locally as applicable, serving as a pillar for community needs, and caring for more than 185,000 individuals and 67,000 children a year. Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer. Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. Applicants will be considered until the position is filled. Denver Health was founded as City Hospital in 1860 to serve the health care needs of the rapidly developing city of Denver. Since then, we have grown alongside the community to become a complete health care system, proudly providing care for all residents -- at every point in their lives. We believe healthy people are the foundation of a vibrant community, and Denver Health has been treating and healing the people of Denver for more than 160 years. Today, Denver Health delivers preventive, primary and acute care services. We are committed to making our community a healthy place to live, work and raise a family. Youll see that commitment in the programs we offer, through the care we provide and in our determination to achieve continuous improvement so our community always has the best care available. As a comprehensive, integrated organization, we provide hospital and emergency care to the public, regardless of ability to pay. This integration promotes continuity of care for each patient and assures health care that is delivered in the most efficient, cost-effective setting. We care for: thirty-three percent of Denver's population annually; Denver Health sees nearly 1,200,000 total patient visits annually. one in three Denver-area children each year. the needs of special populations such as the poor, uninsured, pregnant teens, persons addicted to alcohol and other substances, victims of violence and the homeless. As Colorado's primary safety-net institution, Denver Health has provided uncompensated care and serves as a model for other safety net institutions across the nation.